|Year : 2014 | Volume
| Issue : 2 | Page : 190-194
Autogenous tooth fragment reattachment: A multidisciplinary management for complicated crown-root fracture with biologic width violation
Vinaya Kumar Kulkarni1, Chitra P Bhusari1, Divya S Sharma1, Prashant Bhusari2, Arpana V Bansal3, Jeevanand Deshmukh4
1 Department of Pedodontics and Preventive Dentistry, Modern Dental College and Research Centre, Indore, Madhya Pradesh, India
2 Department of Periodontics, Modern Dental College and Research Centre, Indore, Madhya Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, People's Dental Academy, Bhopal, Madhya Pradesh, India
4 Department of Periodontics, Rishi Raj College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India
|Date of Web Publication||17-Apr-2014|
Vinaya Kumar Kulkarni
Department of Pedodontics & Preventive Dentistry, Modern Dental College and Research Centre, Gandhi Nagar, Airport Road, Indore - 453 112, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Fractures of multiple permanent anterior teeth can be a traumatic experience for children, with functional, esthetic and psychological aspects. The treatment of complicated crown-root fractures (CRFs) is more challenging when the biologic width is violated. This paper presents a case of 12-year boy with complicated CRF of teeth #12 and #21, and horizontal crown fracture of tooth #11. It was managed by endodontic treatment, mucoperiosteal surgery with osteotomy to visualize the fracture line for fragment reattachment, followed by fiber-post placement and restoration with polycarbonate crowns. Clinical and radiographic evaluation after 6 months was satisfactory with adequate functional and esthetic results.
Keywords: Biologic width, crown-root fracture, glass fiber-post, maxillary incisors, periodontal healing, tooth fragment reattachment, traumatic injury
|How to cite this article:|
Kulkarni VK, Bhusari CP, Sharma DS, Bhusari P, Bansal AV, Deshmukh J. Autogenous tooth fragment reattachment: A multidisciplinary management for complicated crown-root fracture with biologic width violation. J Indian Soc Pedod Prev Dent 2014;32:190-4
|How to cite this URL:|
Kulkarni VK, Bhusari CP, Sharma DS, Bhusari P, Bansal AV, Deshmukh J. Autogenous tooth fragment reattachment: A multidisciplinary management for complicated crown-root fracture with biologic width violation. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2021 Jan 26];32:190-4. Available from: https://www.jisppd.com/text.asp?2014/32/2/190/131007
| Introduction|| |
Anterior teeth fractures as a result of traumatic injury are frequently seen in dental practice. A particularly high prevalence has been noted in children between 7 and 12 years of age. ,, In both the dentitions, maxillary central incisors are most commonly affected. 
Crown-root fracture (CRF) has been described as fracture involving enamel, dentin and cementum, occurring below the gingival margin. This type of fracture usually results from a horizontal impact and represents 5% of all dental injuries. Depending on the presence or absence of pulpal involvement, they are classified as complicated or uncomplicated fractures. ,, A CRF often breaches the biologic width which is the sum of the lengths of epithelial and connective tissue attachment to the tooth. 
Literature shows various treatment modalities for CRF in permanent teeth, where the esthetics is severely compromised. These are further influenced by various factors such as the extent of fracture, the patients' age, dental eruption and root formation, alveolar bone fracture, pulpal and periodontal involvement, soft-tissue injuries, presence/absence of fractured tooth fragment, amount of remaining tooth structure, secondary traumatic injuries, occlusion and aesthetics. ,, The use of natural tooth fragments is an excellent biological approach for restoring fractured anterior teeth, when the fragment is available. ,, Biological restoration using autogenous tooth fragment requires minimal healthy tooth preparation, is esthetic, faster than a complete composite restoration and has a psychological benefit to the patient that his own tooth has been retained.  The purpose of this case report is to describe biological restorative treatment in complicated CRF of teeth with violation of biologic width.
| Case Report|| |
The present case report is about a 12-year-old boy reported to the dental outpatient department of the Department of Pedodontics and Preventive Dentistry with the complaint of pain in the upper anterior teeth. A history of trauma 18 days earlier due to a fall was given. No treatment had been performed following the trauma as the patient lived in a village with no access to dental treatment. The patient's medical and family histories were non-contributory.
Clinical examination revealed fractures involving three maxillary incisors. Tooth #12 had oblique CRF from the labial to palatal aspect extending subgingivally. The fragment was mobile and retained with the support of soft-tissue. An oblique crown fracture was seen in tooth #11 with pulp exposure; the fragment, however, was missing. Tooth #21 had a complicated CRF with 3 fracture lines - a mesial fragment involving the incisal edge extending above mid crown level and stopping short of distal angle - this fragment was missing. A second fracture fragment involving the distal half of the crown, extending subgingivally and a third oblique fracture extending palatally and subgingivally. The second and third fragments were mobile and held by soft tissue [Figure 1].
|Figure 1: Intraoral views showing fractured maxillary incisors and the fragments attached by gingival tissue (a) facial view (b) occlusal view|
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Radiographic examination showed the fracture line extending 3-4 mm below the cemento-enamel junction of permanent maxillary left central incisor. Apices of permanent maxillary central incisors were closed and that of maxillary right lateral incisor was near completion [Figure 2]. A diagnosis of complicated CRF was made for tooth #12 and #21 and complicated crown fracture for tooth #11.
|Figure 2: Pre-operative intraoral periapical radiographs showing the extent of fracture (a) showing teeth #11and 12 (b) showing tooth #21|
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Considering various treatment options available and the age of the patient, it was decided to carry-out endodontic treatment followed by mucoperiosteal surgery with osteotomy to visualize the fracture line for fragment reattachment. Cementation of fiber-posts to gain intra radicular retention and esthetic restoration with polycarbonate crowns was also planned.
The fractured fragments were separated from the gingival tissue after administration of local anesthesia. These were cleaned with and stored in distilled water until reattachment procedure. Access was gained to the root apices of fractured maxillary incisors after isolation. Pulp was extirpated, shaping and cleaning of the root canals was performed using endodontic K-files and H-files (Mani, Inc. Utsunomiya, Tochigi, Japan) after the determination of working length. Irrigation of the root canals at every step was done with 5.2% sodium hypochlorite and normal saline. The canals were finally flushed with normal saline and dried with absorbent paper points. The root canals were filled with a paste of calcium hydroxide powder (Deepashree products, Ratnagiri, India) mixed with normal saline. After 1 week when the teeth seemed to be asymptomatic, final obturation of the teeth #12 and #11 was performed using endodontic sealer (Endoflux, Ammdent, Mohali, India) with gutta-percha (Dentsply, France, SAS) by lateral condensation technique [Figure 3]a. Considering the subgingival extent of the fracture of tooth #21, a decision was made to fill the root canal at the time of fragment reattachment. The access cavities were sealed with Cavit - G (3M ESPE, USA).
|Figure 3: Intraoral periapical radiographs after endodontic treatment (a) showing teeth #11and #12 (b) showing teeth #11 and #21|
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The following day, a full thickness mucoperiosteal flap was raised palatally following an internal bevel incision from distal aspect of tooth #12 to distal aspect of tooth #22. Osteotomy was done to visualize the fracture lines of teeth #12 and #21. Root canal filling of tooth #21 was done with gutta-percha (Dentsply, France, SAS) using endodontic sealer (Endoflux, Ammdent, Mohali, India) by the lateral condensation technique [Figure 3]b and [Figure 4]a. The two fragments of tooth #21 were first reattached together with conventional restorative glass ionomer (GI) cement (GC-restorative cement, GC Corporation, Tokyo, Japan). This was then reattached to the exposed fracture line. The fragment of tooth #12 was similarly reattached using GI cement [Figure 4]b.
The flap was replaced and sutured with 3-0 black silk. Periodontal pack was placed both labially and palatally (Coe-Pack, GC America Inc. USA). Post-operative instructions were given. The periodontal pack and sutures were removed after 1 week and the gingiva was found to be slightly inflamed. Tooth #21 showed a grade I mobility and hence a wire-composite splint was placed for a period of 2 weeks.
|Figure 4: Intra-operative photographs (a) palatal mucoperiosteal flap refl ected and root canal fi lling completed for tooth #21 (b) fracture|
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After 2 weeks, all three teeth were re-entered and the canals were prepared for post space. Glass fiber posts (Fibrapost Plus; Produits Dentaire SA, Vevey Switzerland) were cemented with dual-cure composite resin according to the manufacturer's instructions (Sealacore; Produits Dentaire SA, Vevey Switzerland) [Figure 5]. Upon removal of splint, the mobility of 21 was found to be reduced with satisfactory soft tissue healing [Figure 6]. The teeth were prepared to receive polycarbonate crowns as an interim restoration, until a permanent solution at a later age. For esthetic reasons, a polycarbonate crown was placed for the tooth #22. The crowns were cemented with luting GI cement (GC-luting and lining cement, GC Corporation, Tokyo, Japan) [Figure 7].
Clinical and radiographic examinations after 6 months were satisfactory showing no signs of tooth mobility, gingival recession or periodontal pocket formation with the treated teeth [Figure 8] and [Figure 9]. The patient was asymptomatic throughout the period and the teeth were serving their function.
|Figure 5: Intraoral periapical radiograph showing splint in place and cemented glass fi ber-posts|
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|Figure 6: Intraoral view showing healing of the soft tissues after removal of splint|
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|Figure 7: Intraoral views after cementation of polycarbonate crowns (a) facial view (b) occlusal view|
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|Figure 8: Intraoral views after 6 months follow-up (a) facial view (b) occlusal view|
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|Figure 9: Intraoral periapical radiographs after 6 months follow-up (a) showing teeth #11and #12 (b) showing tooth #21|
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| Discussion|| |
The treatment of complicated CRF that involves the biologic width has always been a challenge to the dentist. Various treatment approaches have been proposed which include - removal of coronal fragment with subsequent restoration above gingival level. This allows the subgingival portion of the fracture to heal with formation of a long junctional epithelium. The second option is to convert the subgingival fracture to a supragingival fracture with the help of gingivectomy and osteotomy procedures. The third option is removal of the coronal fragment and surgical extrusion of the tooth, in order to reposition the fractured margins to a supragingival position. In surgical extrusion the periodontal ligament may fail to reattach to the root surface and remarkably increases the risk of root resorption. The fourth modality of the treatment is removal of the coronal fragment and subsequent orthodontic extrusion of the tooth.  However, there is decrease in the crown - root ratio and cervical diameter of the extruded tooth is smaller than the contralateral tooth, thus compromising esthetics.  The fifth option is extraction followed by removable or fixed prostheses/implants.
Reattachment of the fragment is a conservative technique that restores function and esthetics in a single visit procedure. It also provides natural bulk to the tooth when final restoration is planned at a later stage.  Bonding of the fragment also promotes subgingival healing with a long junctional epithelium. 
The biocompatibility of GI cement used in subgingival restorations has been extensively studied over many years and its therapeutic advantages over other restorative materials have been documented. GI cement has desirable properties like its ability to set in the presence of moisture, chemical adhesion to tooth structure and antibacterial property. , It has also been found to promote epithelial and connective tissue reattachment  and also stimulate bone formation. 
A study done by Leyhausen et al.  evaluated the cellular compatibility of light curing GI cements (Compoglass, Ionoseal and Vitrebond) and a conventional GI cement (Ketac) through cell culture tests. Human primary fibroblasts of the attached gingiva (human gingival fibroblasts) and permanent mouse fibroblasts (3T3) were used for the experiments. GI cements Compoglass, Ionoseal and Ketac showed good cellular compatibility though Vitrebond was found to be cytotoxic.
Dragoo  restored 50 subgingival lesions with two resin-ionomer cements and one hybrid - ionomer cement in 25 patients. At the 1 year follow-up, the gingival recession was found to be minimal, with a decrease in probing depths and gain in attachment with all materials tested. Histological findings were suggestive of epithelial and connective tissue adherence to the restorative materials during the wound healing process.  Recently, Biniraj et al.  restored a fast resorbing traumatized canine root with GI cement (Fuji II). Review radiographs up to 18 months showed bone regeneration around the restoration.
In fractures involving two-thirds or more of the crown, post systems are usually recommended.  In the presented case, the fractures were below the gingival margin, involving the biologic width. Hence, it was decided to gain intra-radicular retention for the fractured tooth fragments by using glass fiber posts. Maintenance of adequate hydration of the fracture fragments when they are outside the mouth is another important factor to ensure adequate bond strength. If a tooth fragment is maintained in a dry state for more than 1 h, it will achieve lower bond strength  and must be rehydrated for at least 30 min before bonding.  Hydration also maintains original esthetic appearance of the tooth.  In the presented case, the fractured fragments were preserved in distilled water until reattachment.
Advances in the field of biomaterials have opened-up new avenues in the treatment of fractured teeth. The important factor to consider is adequate fit and contour of the margin of subgingival restorations. In the present case, the sealing ability of the materials used along with a good adaptation of the fragment and proper fit and contour of the margin may be responsible for the favorable outcome. The periodontal lesion that is caused by violation of biologic width is multifactorial and depends on plaque formation, host response and quality of restoration. It has been affirmed by Ramfjord  that the organism is able to form a new biologic width or adapt itself to restorations as long as the patient maintains good plaque control.
| Conclusion|| |
An attempt was made to salvage a fractured tooth with questionable prognosis. The combination of dental fragments, adhesive dental materials and restorative materials that are available today provide good functional and esthetic results. Connecting these properties with an alternative treatment plan in the restoration of extensively damaged teeth, with violation of the biologic width has been presented. Access to the fracture margins was gained by means of mucoperiosteal flap and osteotomy procedure; facilitating biological restoration with autogenous tooth fragment. This case also demonstrates the beneficial effects of tooth fragment reattachment on periodontal health and normal functioning of the teeth. Although the initial results are encouraging, a long-term follow-up is required to confirm the periodontal stability of the affected teeth.
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